Human Papillomavirus Vaccination Before and During the COVID-19 Pandemic
Every clinical encounter is an opportunity to vaccinate. The COVID-19 pandemic disrupted in-person encounters, leading to delays in childhood vaccinations across different seasonal patterns.1,2 Historically, human papillomavirus (HPV) vaccination has lagged behind other adolescent vaccinations.3 Strategies to catch up by offering vaccines at every encounter starting at age 9 years4,5 and prioritizing population subgroups are needed. We characterized HPV vaccination by age and season from 2019 to 2021 and compared vaccination by encounter before and during the COVID-19 pandemic to identify catch-up priority groups.
This cross-sectional study assessed encounters from January 2019 to December 2021 of patients aged 9 to 22 years at Children’s Health Medical Group, Dallas, Texas, who were seen for well or follow-up visits, with no change in HPV vaccine supply or availability during the study period. The study was approved by the University of Texas Southwestern Medical Center institutional review board, with a waiver of informed consent because this was a nonregulated quality improvement project. The STROBE reporting guideline was followed.
Structured queries of electronic health records were used to identify patients due for an HPV dose and whether it was received at an encounter. Demographic characteristics and encounter features (eg, order during study period) associated with HPV vaccination were assessed using Mann-Whitney tests adjusted for nonindependence of observations. To understand pandemic effects and seasonal variation, difference-in-difference testing compared total vaccines administered each season in each year.2 A priori significance was set at 2-sided P ≤ .05. Analyses were performed used Stata, version 15.
Among 4548 patients with 10 469 encounters (Table 1), the percentage receiving HPV vaccination was higher in 2021 (1118 of 3522 [35.0%]) and 2020 (1182 of 3320 [35.6%]) compared with 2019 (1222 of 3957 [30.9%]) (P < .001) despite a 19.3% decrease in the number of encounters in 2021 (n = 3192) compared with 2019 (n = 3957). The youngest eligible age group (9-10 years) had the lowest percentage of vaccinations compared with other age groups, representing 3629 of 10 469 encounters (34.7%) but only 10 of 3522 vaccinations (0.3%).
Table 2 compares the adjusted percentage change in vaccinations per season. In 2020 compared with 2019, there was an 17.99% increase in vaccinations during the winter. At the beginning of the COVID-19 pandemic in spring and summer 2020, vaccinations changed by −37.31% and −22.30%, respectively, and by 37.37 % in fall. In 2021 compared with 2020, vaccinations changed by −11.66 % in winter, 44.64% in spring, −3.85% in summer, and −28.33% in fall. In 2021 compared with 2019 (before the pandemic), vaccinations changed by 4.23% in winter, −9.33% in spring, −25.29% in summer, and 6.97% in fall.
We found a steady increase in HPV vaccinations per encounter between 2019 and 2021 despite an 19.3% decrease in overall encounters. The pandemic may have been associated with providers feeling pressured to not miss vaccination at in-person encounters. The number of unique patients was unchanged during the pandemic, which was likely true for other settings. A study limitation is that encounter-level data are useful for clinicians to understand day-to-day vaccine performance but cannot be compared with patient-level state or national data.
Patients aged 9 to 10 years were the least vaccinated even though the practice recommended vaccinations at all encounters. Future studies with larger samples should evaluate age and sex together to assess disparities. Also, vaccination levels in summer of 2020 and 2021 did not catch up to prepandemic vaccination levels in 2019 despite summer typically having more well visits and sports-related examinations. Of note, HPV vaccinations in winter 2020 vs 2019 were largely unchanged, a control for this unadjusted analysis. Efforts to catch up and surpass prepandemic vaccination levels should consider age and seasonality to forecast patient need and adjust vaccine stock and storage to ensure HPV vaccination does not decrease further.
Accepted for Publication: August 12, 2022.
Published: September 19, 2022. doi:10.1001/jamanetworkopen.2022.34000
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Francis JKR et al. JAMA Network Open.
Corresponding Author: Jenny K. R. Francis, MD, MPH, Department of Pediatrics, Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390 (jenny.francis@utsouthwestern.edu).
Author Contributions: Dr Francis had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Francis.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Francis, Weerakoon, Mathew.
Critical revision of the manuscript for important intellectual content: Francis, Weerakoon, Lucas, Durante, Kelly, Tiro.
Statistical analysis: Francis, Weerakoon.
Obtained funding: Francis.
Administrative, technical, or material support: Francis, Lucas, Mathew.
Supervision: Francis, Durante.
Conflict of Interest Disclosures: Dr Lucas reported receiving grants from the American Cancer Society during the conduct of the study. Dr Tiro reported receiving grants from the National Institutes of Health and Cancer Prevention and Research Institute of Texas outside the submitted work. No other disclosures were reported.
Funding/Support: This work was supported by the American Cancer Society HPV Cancer Free Texas and grant K23 HD097291 from the National Institutes of Health (Dr Francis).
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: We thank the research team, specifically the clinical staff at Children’s Health System of Texas. Stephanie E. Trenkner, MD, and Sonia Allouch, MD (Department of Pediatrics, University of Texas Southwestern Medical Center and Children’s Health System of Texas), attended meetings and reviewed vaccine data as part of a scholarly project. They were not compensated for their role.
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